Provider Demographics
NPI:1114093481
Name:WAMPLER, TRACY JANESE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:JANESE
Last Name:WAMPLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20135 VEJAR RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2333
Mailing Address - Country:US
Mailing Address - Phone:909-594-1691
Mailing Address - Fax:
Practice Address - Street 1:10454 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2444
Practice Address - Country:US
Practice Address - Phone:626-453-8466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7313363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health